Pic 0: A title card appears before transitioning to Dr. Owens in front of a blank background.
Opioid use disorder frequently starts with prescription opioid medications that patients may misuse to get high. So, it can seem counterintuitive to say that the best way to treat it is with more prescription medicines, some of which are opioids!
This has led some healthcare professionals, addiction specialists, and policy makers to dismiss medication-assisted treatment as "just replacing one drug with another."
Pic 1: Text appears next to her which reads “Safe and Effective, Mitigate Symptoms, Promote Recovery.”
But that's a fundamental misunderstanding of how pharmacotherapy works. Its goal is to use safe and effective medication along with counseling and behavioral supports to mitigate the symptoms of OUD and allow patients the best chance at recovery.
Pic 2: The text is replaced by new text which reads “FDA-approved medications:” with the examples “Methadone, Buprenorphine, Naltrexone.”
Three medications have been approved by the FDA for the treatment of OUD: methadone, buprenorphine, or naltrexone.
Let’s look at each of them.
Pic 3: The screen changes to one titled “Methadone,” with an upside-down green triangle next to it. Below the title is an image of a transparent head which reveals the brain with a series of white circles at different places on it. An arrow appears, pointing to the most forefront circle, connecting it to the image of a white rectangle with a curved top and a pointed space into which the green triangle inserts itself. Text below this image identifies it as an “opioid receptor.” The text above the image reads “Full Agonist.” After the triangle has been inserted, the small white circles on the brain turn green and begin to pulse.
Methadone has been in use the longest. It's a full agonist, meaning that it binds to the opioid receptors in a patient's brain and the response it produces is directly proportional to the dose. It's an opioid, but it metabolizes slowly enough for patients to take it once a day, without the peaks and valleys seen with opioid pain relievers. It reduces withdrawal symptoms, helps to control drug cravings, and blocks euphoric effects at the appropriate dose.
Pic 4: The screen changes to one titled “Methadone Benefits” and includes the following list:
Full agonist binds to opioid receptors, proportional response
Metabolizes slowly
Reduces cravings and withdrawal symptoms
Blocks euphoric effects so users can’t feel “high” if they use another opioid
Pic 5: The screen changes to a new one, this one titled “Additional Methadone Considerations.” An image of an unbalanced scale appears on screen. Underneath, text appears that reads “Patients must visit specialized treatment programs. At least 6 days per week.”
But by law, methadone for the treatment of OUD can only be administered in specialized opioid treatment programs. Methadone treatment requires that patients visit the treatment programs at least six days per week for the first few months. This can be challenging for many patients.
Pic 6: The title remains the same, but the screen transitions into an image of a list, which includes
Some patients don’t have a clinic nearby or can’t come daily
Stigma associated with methadone
Has strong analgesic properties for patients with OUD and chronic pain
Methadone is an opioid, with potential for misuse and diversion, which is one reason on-site observed dosing is required
Can lead to overdose if taken at high doses or mixed with other respiratory depressants
Pic 7: The screen changes to one titled “Buprenorphine” with a small blue circle next to it. The image of a brain with white circles appears again, but this time the secondary image shows a triangle of blue circles being inserted into the white round-topped rectangle. The text below identifies this as an “opioid receptor.” The text above this image reads “Partial Agonist.” Like last time, once the blue circles are inserted, the white circles begin to pulse, but less so than in the Methadone slide.
Buprenorphine is an opioid medication that, like methadone, blocks euphoric effects, reduces withdrawal symptoms, and controls drug cravings. It is prescribed by physicians and taken at home. It's a partial agonist, meaning it binds to the brain's opioid receptors but triggers only a limited response
Pic 8: The screen changes to one titled “Buprenorphine Benefits.” It contains the following list
Partial agonist, which means it binds to opioid receptors, but does not fully activate the receptor. It leads to “ceiling effect” or no increased effect from higher doses.
Available by prescription in office-based setting, and can be taken at home.
Eliminates withdrawal symptoms and reduces cravings
Blocks euphoric effects of opioids, especially for users with high tolerance
Lower risk of overdose
Pic 9: The screen changes to one titled “Additional Buprenorphine Considerations” with the image of an unbalanced scale with the text “Complete additional training, obtain a special DATA-2000 waiver and DEA license to prescribe” underneath.
However, prescribers must complete additional training and obtain a special DATA-2000 waiver and DEA license to prescribe buprenorphine as treatment for OUD.
Pic 10: The title remains but the image and text is replaced with a list which includes
Requires additional training (8 hours for physicians, 24 hours for NPs or PAs) and DATA-2000 waiver to prescribe.
Federal limitations on the number of patients a physician can treat at one time: 30 the first year, 100 the year after, can increase to 275 per year in the third year if qualifications are met
Potential for diversion. Has street value, so patients could sell prescribed drugs
As a partial agonist, analgesic properties are not as strong as full agonists
Pic 11: The screen changes to one titled “Naltrexone” with an image of a purple line which curves down a little on either side next to it. It has the same brain image, but in the secondary image this time the purple line covers the opioid receptor like a lid. Text below identifies it again as an “opioid receptor.” The text above the secondary image reads “Antagonist.” After the lid covers the opioid receptor, the white circles on the brain are replaced with purple Xs.
Naltrexone works differently than methadone or buprenorphine, because it acts as an antagonist on opioid receptors, producing no effect and blocking the effects of opioids.
Pic 12: This slide is titled “Naltrexone Benefits” and contains the following list
Antagonist, it blocks opioid receptors, does not activate
Not a controlled substance, any licensed prescriber can prescribe
No potential for diversion and misuse
No risk of overdose
Available in extended-release version
Pic 13: This next slide is titled “Additional Naltrexone Considerations.” Text appears below which reads “Doesn’t block withdrawal. Can precipitate acute withdrawal.”
But, as an antagonist, Naltrexone doesn’t block withdrawal and can precipitate acute and painful withdrawal if taken by someone who has opioids in their system.
Pic 14: The title remains, and the previous text is replaced by this list
Requires 7 to 14 days of detoxification before using or can cause acute withdrawal
Daily oral dose not effective for opioid use disorder treatment
Injectable extended release formulation has benefits but low retention rates
Pic 15: The screen returns to a close-up on Dr. Owens.
Decades of moralizing about addiction might make us want to help patients "quit" or "get clean." Controlling an addiction with medication might feel like an uncomfortable compromise.
Pic 16: The screen changes to one with three figure silhouettes. One is yellow, and has the label “Type 2 Diabetes” over its head. Another is red, and has the label “Hypertension” above its head. The last is blue, and has the label “Depression” above its head. After a moment, a syringe appears next to the yellow silhouette, and a pill next to the red and blue ones.
But the truth is, many chronic conditions that have strong genetic, environmental, and behavioral components require regular medication along with behavior change
Pic 17: The screen returns to a close-up of Dr. Owens.
And pharmacotherapy for OUD is tremendously effective. Receiving buprenorphine or methadone halves the likelihood that patients will die of overdose, compared to those receiving counseling alone.
With MAT, instead of experiencing the powerful highs and lows of cravings and withdrawal, patients experience steady relief. This helps keep their moods and health stable enough for them to participate in counseling and rebuild their lives. Like with other chronic conditions, some patients may eventually taper off these medications, while others may need ongoing pharmacotherapy.
Pic 18: A red cross appears next to the word “Recovery.” Below a series of bullet points appear then disappear, including “Improve health and wellness,” “Live self-directed lives,” and “Strive to reach their full potential.”
Using medication to treat OUD helps people achieve recovery, which SAMHSA defines as "a process of change through which individuals with substance use disorders improve their health and wellness, live self-directed lives, and strive to reach their full potential.”
Focusing on the health, wellbeing, and function of people with OUD goes hand in hand. By moving the discussion of OUD from a moral model to a medical one, we ensure that we're using evidence-based treatments like pharmacotherapy to provide the best standard of care.
Pic 19: The screen changes to one which contains the following text, “In 2014, an Australian study on patients with OUD leaving prison found that being on either methadone or buprenorphine reduced their risk of death by 75 percent.” It includes the citation “Degenhardt, Louisa, et al. Addiction Research Report, 2014.”
Pic 20: The screen changes to one with text that reads “France instituted a ‘low threshold model’ that let doctors prescribe methadone and buprenorphine on demand. Between 1995 and 2004, France saw an 80 percent reduction in overdose deaths.” It includes the citation “Auraicrombe, M et al. American Journal on Addictions, 2004.”
Pic 21: This slide reads “The World Health Organization includes both methadone and buprenorphine on the WHO Model List of Essential Medications because of their enormous impact in reducing crime, infectious disease, and overdose.” The citation reads “http://www.who.int/medicines/publications/essentialmedicines/en/ “
Pic 22: The screen returns to Dr. Owens.
Even if you have reservations about using an opioid to treat opioid use disorder, it is important to recognize that without such treatment, your patients' risk of overdose is significantly higher.
Pursuing a goal of recovery, and embracing every means to achieve it, will help more people with OUD survive and live happy, stable lives. So, how do we reach patients who are struggling with this disorder?